30C-075 (2) •
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'Board crt Build . Rc_�uI:z iun� and �t:,ntlartis
Construction Suter!: :sor Lice:Isz
• License: CS 67121 .
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• BRiAN G THOMPSON ,t •
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WESTFIELO, MA•Cf:185
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I'I.EASE READ THIS
Sold, Furnished and Installed by:
Ch i Boston batee THD At*Home Services, Inc -
,/,j (Vb/a The Home Depot At-Home Services
345A Greenwood Street, Unit 2, Worcester, MA 01607
Toll Free (800) 657-5182; Fax (508) 756 -8823
Branch Number. 31 Federal ID #75-2698460: ME Lie it C 02439; RI Cont. Lie* 16421
Cr Lie * MC.0565522: MA Home improvement Contractor Reg.* 126893
Irrnalation Address: Jt .t2 PL4 e. l i .Ear
city stare Zip
1Pcrrchoset(s): Work Phone: Hoist Phone: Cell Phone:
k I. - [ ]
[ J [ ] [ 1
Home Address:
(If different from installation Address) City state Zip
E-mail Address (to receive project communications and Home Depot updates):
❑ I DO NOT wish to receive any marketing emails from The Houle Depot
Proi Information: Undersigned ( "Customer"), the owners of the property located at the above installation address, agrees to buy,
and TI4D At -Home Services, Inc. ("The Home Depot ") agrees to furnish, deliver and arrange for the installation ( "Installation ") of
all materials described on the below and on the referenced Spec Sheet(s), all of which are incorporated into this Contract by this
reference, along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders (collectively.
"Contt-set');
John. 11.1....e a.r,.�n
-�
• gems i •' • , 'i allows • Insulation
, � a 4 3 6 ( oGr rs / Cwas II Entry Doors ❑ 'i t 6 s $
■ • , is • i Windows i insulation
❑Gonna / Covers Claim Doors l
■ • •Siding i Windows is htautstian
Dow a l Covers ❑Parry Poars D G'
• , t ••_ • idles ■ Windows II Imitation $ •
OGuttas / Coven Crawly Doors ri
Arminian 25% Depose d Comma Anima daeup/me alibis contract Tom ConhxtAmount $ Li. J (
moist PeitLan setrynetdepsitsaeO maoe4lodofIlseCoatrad.Awornt
Customer agrees that, immediately upon completion of the work for each Product. Customer will execute a Completion Certificate
(one for each Product as defused by an individual Spec Sheet) and pay any balance due. As applicable, each Customer under this
Contract agrees to be jointly and severally obligated and liable hereunder.
The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s) 'Deluded herein, at
its discretion. if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural
problem with the home, environmental hazards such as mold, asbestos or lead paint other safety concerns, pricing errors or because
work required to complete the job was not included in the
Payment Summary- e The Payment Summary # J , included as part of this Contract, sets Noah the total
Contract amount and payments required far the deposits and final payments by Product (as applicable).
NOTICE TO CUSTOMER
You are entitled to a Need -in copy of the Contract at the dine on sign. Do not sign a Completion Certificate (note:
there is one Completion Ieion Cerh'fteaae for each listed Prods et as (ldmed by mdividaal Spec Sheets) before work on that Product
h oonmiete.
In the event of teestaination of this Contract, Customer agrees to pay The Home Depot the costs of materials, labor, expenses
and services provided by The Home or Authorised Service Provider thronah the date of terra on, plus any other
antorasts set ibrat ha ibis Agreement or wed under OWED TO THE HOME DEPOT THE D� PAYMENT OR OTHER PAYMENTS KENTS MADE, A MOUNTS WTTHOOT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acceptance lira Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer
and The Home Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements, either
oral or written, relating to said Products and Installation. This Agreement cannot be assigned or ascended except by a writing signed
by Customer and The Rowe ► • . Customer acknowledges and agrees that Customer bas read. understands, voluntarily accepts the
to of and has received a • • • ' Agreement
44111VirIP Su
X X Date C 's Signature Date Sales Consultant's Si
x Telephone N0.'`fl. 49
Customer's Signature Date Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS ouwer
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON M E THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE,
NOTICE: ADD111ONAL TERMS AND cOrMertne5 ARE STATED ON THE REVERSE SIDE AND ARE PART OP ram CONFRACr
0r.ia.i1 C-SG r+a write - Branch Pis Yellow — Customer
he CO :MM ran -Amit o l''2ssan a 14sems`s•
— = Department of industrial Accidents a
i:Li
A r.. Office of Investigations
M M p
or aw :P,. 4
. _. 600 'ash,ington Street
' 4 Boston, MA 02111
rW.r wwW rnass.gov/dia
Workers' Compensation Insurance .Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): r 1i4l t i "' i`( er5t ,
Address: G 4 r of .1!"'r ■ A R .
City/State/Zip: M1 A AL _ ' Phone #: ID �� i
Are yo an employer? Check the appropriate box: Type of project (required):
1. I am a employer with 4. 0 I am a general contractor and I
- -
-------- - ___ �� 5 0 New construction
employees (full and/or part-time) * have - hired - the sub contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. .7. 0 Remodeling
— These sub- contractors: have
ship and have no employees : _
(� Demolition
- 8.
for in any capacity. employees and have workers'
working .
g Y P ty 9. E] Building addition
P. x'.
[No workers' comp. insurance
comp. insurance 10.0 Electrical repairs or additions
required.] 5. Q We are a corporation and its
3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roo repairs
insurance required.] t c. 152, §1(4) and we have no ,
employees. [No workers' 13. ther ' 11
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have
employees. If the sub- contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. r J b , . —
Insurance Company Name: � 0,3 l�l',V7 i 1� r -, 6 2________________
Policy # or Self -ins. Lic. #: - 01 l 9- Expiration Date: -
V II .ILA ., - - Job Site Address: -- . tk`�� I ! /4 City/State/Zip: I , i t /I s ! /-- 1 �
copy compensation n policy declaration page (showing the policy number and expi ation date).
Failure to secure coverage as under er Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day - .. inst the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of th4.r insuranc- overage verification.
Id hereby ce 'y• under t Id pe Ides of perjury that the information provided above is true and correct-
- ■ Si: a -: /i l _ Date: ,
Phone #: D b ��
•
Official use only ; Do not write-in-this -area,-to-be completed by city or town- official
City or Town: Permit/License # —
:_Issuing Authority (circle one):
1. Board 2 f Health ildr.g nepar t 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing I for
Q I� ?. � i
:: tT.er: ! t. .�. ' : �Cl.°. a..`i3.e�.vr � ausiauaiag nsY2� s-
6. Other
Contact Person: Phone #:
,
SECTION 8 - z'CONSTRUCTION SERVICES
NW'
8.1 Licensed Construction Sq.,ervisor: Not Applicable 0
Name of License -older: &570
License Number
-
I i IYAIr
Address Expiration Date
A'
_ 1 • ,re
Signatur- Telephone
gi4R6 ere& dimedrii . (overlie itoriffactoi. ti*:',:f,t5V1MtelPeggittlWrilieZa Not Applicable 0
1 IS L6
Company Name Registration Number
- _Address - Expiration Date
-
b. 0.1.1111411/,.. a .1 elephone .21),97
1._SEC
Workers Compensation Insurance affidavit m be completed and subMitted With this application. Failure to provide this affidavit will result
• in the denial of the issuance of the buildin errnit.
Signed Affidavit Attached Yes No 0
9,F4g46,
t!"
agIC,, ° wile el -:, ° 9111
The current exemption for "homeowners" was extended to include Owner-occupied Dwellings of one (1) or two(2) families
• and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
• as supervisor. C11112 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person (s) who own a parcel of land on which he/she resides or intends to reside, which there
is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm
structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such "homeownee submit Building Official, on a form acceptable to the Building Officialthat he/she shall be
- -
responsible for all such work performed under the building permit:
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be alvi cl e tha with reference to Chapter 132(WoilcerS' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
_ Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature • - •
_ „ • ,
_ _ •
•
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Wi ows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition El New Signs [0] Decks [E] Siding [0] Other [0]
Brief Description of Proposed �` ...-: — I r
Work: _ 4w4 i �i // /� )m . ' IL_- - ,
Alteration of existing bedroom Yes No Adding new bedroom Yes No KOtI
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition to fisting housing, complete the following:
a. Use of building : One Family ✓ Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPUES FOR BUILDING PERMIT
I, L - � ' In-
7 , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
I l iql i
Signature of Owner Date
I, '/ - 1,('1 , as Owner /Authorized
Agent hereby declare that the statem and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed und •li pains.. nd •enalties of perjury.
Print Na
- _ , -1 ! P'
Signatur of • 4/ ' g- t Date
560 BURTS PIT RD BP- 2012 -0679
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30C - 075 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit # BP- 2012 -0679
Project # JS- 2012 - 001170
Est. Cost: $4313.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 67121
Lot Size(sq. ft.): 33279.84 Owner: DUNN JENNIFER L & SETH J
Zoning: SR(100) / /WSP Applicant: HOME DEPOT AT HOME SERVICES
AT: 560 BURTS PIT RD
Applicant Address: Phone: Insurance:
345 GREENWOOD ST UNIT 1 (508) 341 -9401 Workers
Compensation
WORCESTERMA01607 ISSUED ON:1/26/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House # Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 1/26/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner